HomeMy Public PortalAbout9711 RICHMOND WAY_Plumbing__ �;OkORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I, herebj M{irrrf that I have a certificate of consent to self 76A667A
,irtsure,�pr a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
`.0`a�cer Ified abpy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES r BUILDING AND SAFETY
Policy No.IV862379 Umpany F emnni- ',�
Certified copy is-hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING -
Certified copy is filed with the county building inspec- ADDRESS Richmond Way '
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCbLITY -
WATER CLOSET I I �eWle Cit
Date 10-16-86 Appli4anPTt -PTS NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by MAIL
SHOWER Owen Devel t
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 2035 S. Myrtle Ave.
I certify that In the performance of the work for which this
permit is issued,I shall not employ-an'y person In any manner SINK CITY • MOrirOVla TEL.NO459-3211
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR Owen Bros. Plumbing, Inc
'Date Applicant CLOTHES WASHER ADDRESS 4265 N. Baldwin Ave.
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte TEL.N043-0078
with comply with suchprovisions or this permit shall be STATE. LIC:
deemed revoked. / WATER HEATER /_ LICENSE NO. 231 741 . C C36-20
LICENSED CONTRACTORS DECLARATION cs/ DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing,with Section 7000)of Division 3 of the Business OUTLETS OVER �.
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL �� VALIDATION
License Number 7�1 7_al Lic.Class�'�F-7n DATE
FIN (C,',
Contractor Olden •BmS_ Pl licmate 1(1-1 A-86 B a
❑ Fam exempt under Sec.
FC•,
B.BP.C. for this reason
Plan check fee
® ; a
Date: PLUMBING PERMIT ISSUING FEE$ 5D Z
Signature
TOTAL FEE JAV
Plan check applicant
•SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following-reason (Section 7031.5, Business and
Professions Code): City Tel. No, t� .� ` �;•,
I, as owner of the property, will do the.work and the
structure is not intended or offered for sale (Section ® ` •� `+t N,\
7044; Business and Professions Code).
r �+ ;
CONSTRUCTION LENDING AGENCY A;58Q2A ,
• `-
I hereby affirm that there is a construction lending.agency for # 0 0 0 o.0 5•
the performance of the work for which this permit is issued '1
(Sec. 3097,Civ. C.). i I o 1 0 Q 5 0
Lender's Name 0 0 1. O Q 5 0 1
Lender's Address
IQ29-8.6
'i certify that I have read this application and state that the
above information is correct. I agree to comply with all County ti
ordinpolo
ances and State laws regulating Plumbing, and hereby
authorize representatives o is County to enter upon the
e-me i ed pro rty nspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
10-16-86
S nature of Permute ` I Date